Socioeconomic Disparities In Mortality Research Articles

Socioeconomic Disparities in Healthcare Access and Implications for All-Cause Mortality among US Adults: A 2000-2019 Record Linkage Study.

The United States (US) has witnessed a notable increase in socioeconomic disparities in all-cause mortality since 2000. While this period is marked by significant macroeconomic and health policy changes, the specific drivers of these mortality trends remain poorly understood. In this study, we assessed healthcare access variables and their association with socioeconomic status (SES)-related differences (exposure) in US all-cause mortality (outcome), since 2000. Our research drew upon cross-sectional data from the National Health Interview Survey (NHIS, 2000-2018), linked to death records from the National Death Index (NDI, 2000-2019) (n=486,257). The findings reveal that the odds of a lack of health insurance and unaffordability of needed medical care were over two-fold higher among individuals with lower education, compared to those with high education, following differential time trends. Moreover, elevated mortality risk was associated with lower education (up to 77%), uninsurance (17%), unaffordability (43%), and delayed care (12%). Uninsurance and unaffordability accounted for 4-6% of the disparities in time to mortality between low- and high-education groups. These findings were corroborated by income-based sensitivity analyses, emphasizing that inadequate healthcare access partially contributed to socioeconomic disparities in mortality. Effective policies promoting equitable healthcare access are imperative to mitigate socioeconomic disparities in mortality.

Socioeconomic Disparities in Neurodegenerative Disease Mortality: A Population-Based Study among Belgian Men and Women Aged 65 or Older.

This study investigates the association between socioeconomic position (SEP) - in terms of income and education - and mortality from neurodegenerative diseases, that is, dementia, parkinsonism, and motor neuron diseases (MNDs). We calculated age-standardized mortality rates and mortality rate ratios using log linear Poisson regression for different SEP groups, stratified by gender, age-group, and care home residency, utilizing the 2011 Belgian census linked to register data on cause-specific mortality for 2011 to 2016. Mortality was significantly higher in the lowest educational- and income groups. The largest disparities were found in dementia mortality. Income had a strong negative effect on parkinsonism mortality, education a positive effect. We found no significant association between SEP and MND. Our study provides evidence supporting the presence of socioeconomic disparities in mortality due to neurodegeneration. We found a strong negative association between SEP and NDD mortality, which varies between NDD, gender and care home residency.

Race and socioeconomic disparities in mortality and end-of-life care following aneurysmal subarachnoid hemorrhage.

This study explores racial and socioeconomic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care, highlighting the impact on treatment and outcomes. The study aims to shed light on inequities and inform strategies for reducing disparities in healthcare delivery. In this cohort study the National Inpatient Sample database was queried for patient admissions with ruptured aSAH from 2016 to 2020. Multivariable analyses were performed estimating the impact of socioeconomic status and race on rates of acute treatment, functional outcomes, mortality, receipt of life-sustaining interventions (mechanical ventilation, tracheostomy, gastrostomy, and blood transfusions), and end-of-life care (palliative care and do not resuscitate). A total of 181 530 patients were included. Minority patients were more likely to undergo treatment (OR 1.15, 95% CI 1.09 to 1.22, P<0.001) and were less likely to die (OR 0.89, 95% CI 0.84 to 0.95, P<0.001) than White patients. However, they were also more likely to have a tracheostomy (OR 1.47, 95% CI 1.33 to 1.62, P<0.001) and gastrostomy tube placement (OR 1.43, 95%CI 1.32 to 1.54, P<0.001), while receiving less palliative care (OR 0.75, 95% CI 0.70 to 0.80, P<0.001). This trend persisted when comparing minority patients from wealthier backgrounds with White patients from poorer backgrounds for treatment (OR 1.10, 95% CI 1.00 to 1.21, P=0.046), mortality (OR 0.82, 95% CI 0.74 to 0.89, P<0.001), tracheostomy tube (OR 1.27, 95% CI 1.07 to 1.48, P<0.001), gastrostomy tube (OR 1.34, 95% CI 1.18 to 1.52, P<0.001), and palliative care (OR 0.76, 95% CI 0.69 to 0.84, P<0.001). Compared with White patients, minority patients with aSAH are more likely to undergo acute treatment and have lower mortality, yet receive more life-sustaining interventions and less palliation, even in higher socioeconomic classes. Addressing these disparities is imperative to ensure equitable access to optimal care and improve outcomes for all patients regardless of race or class.

Socioeconomic Disparities In Mortality And Health Care Use During The COVID-19 Pandemic: Evidence From Germany.

Across the globe, populations with low socioeconomic status have borne a disproportionate burden of the COVID-19 pandemic. This article examines the relationship between two socioeconomic factors (education and income) and all-cause mortality and health care use to improve understanding of the impact of the pandemic on socioeconomic disparities in Germany, a high-income country with a universal health care system. We used mortality rates from the period 2011-21 and hospitalizations from the period 2014-21. We examined rates of all-cause mortality and all hospital admissions as well as admissions for respiratory, emergency, cancer surgery, elective, and ambulatory care-sensitive care. Although the use of some health care services was affected by the pandemic, our findings suggest that Germany endured COVID-19 without amplifying socioeconomic disparities in all-cause mortality and large segments of inpatient utilization.

Social inequality in mortality associated with neurodegeneration: a population-based study in Belgium

Abstract Background Worldwide, population is ageing, leading to a growing burden of neurodegenerative diseases (NDDs) such as Alzheimer's Disease (AD), Parkinson's Disease (PD). Socioeconomic position (SEP) has shown a persistent negative relationship with mortality over the last decades. The most common indicators of SEP such as income, education, and occupational class have shown to significantly impact life expectancy and other mortality indicators. However, studies on the association between SEP and NDD mortality are rather scarce. Therefore, the aim of this study is to assess whether SEP is associated with NDD mortality, which is crucial in understanding and developing preventive interventions for these diseases. Methods A comparative analysis on SEP - in terms of income and education - and deaths associated with dementia and parkinsonism was performed, using log linear Poisson regression. Data consisted of the 2011 Belgian census linked to mortality data for the period 2011-2016. Results During the 2011-2016 study period, 34,700 Belgian inhabitants aged 65 or older died from an NDD (N = 1,883,182). We observed significantly higher mortality in the lowest educational- and income groups. Education had the strongest association in women, with 1.29 (CI 1.21-1.38) times the MRR in the lowest educated group compared to the highest. In men, income showed the strongest association with 1.11 (CI 1.04-1.18) times the MRR in the lowest income group compared to the highest. The biggest disparities were found in dementia mortality, generally negative association with SEP. For income, we observed a strong negative association on parkinsonism mortality, while we found a reversed pattern with education. Conclusions Our study provides evidence supporting the existence of socioeconomic disparities in mortality due to neurodegeneration. We found a strong negative association between SEP and NDD mortality, which varies between men and women and between several NDDs. Key messages • NDDs are rapidly becoming a major public health issue worldwide. • Mortality from these diseases vary between different social groups, differentiated interventions are needed in order to reduce inequalities.

1426-P: Socioeconomic Disparities in Mortality among Young Adults with Diabetes—A Nationwide Cohort Study in South Korea

Objectives: This study aimed to estimate the overall and cause-specific mortality risk according to socioeconomic status (SES) and age among patients with diabetes. Research Design and Methods: From the Korean National Health Insurance Service Cohort (2008-2019), 1,240,780 adults aged 20-79 years (604,975 patients with diabetes and 635,805 controls without diabetes) were included. The risk of mortality from any causes, cardiovascular disease, diabetes, and cancer was estimated according to the patients’ SES and compared with age- and sex-matched controls without diabetes. The SES was categorized into three groups (tercile) by subjects’ income. Subgroup analyses were done according to the individuals’ age group (20-39, 40-59, and 60-79 years). Results: Overall, 48,420 deaths occurred during a follow-up. Compared with individuals without diabetes, the adjusted hazard ratios (HR) of all-cause mortality of patients with diabetes were 1.25 (95% confidence interval (CI), 1.23-1.28) in the highest SES, 1.56 (95% CI, 1.53-1.59) in the middle SES, and 1.78 (95% CI, 1.74-1.82) in the lowest SES group. The inverse relationship between SES and mortality risk was prominent in younger patients; the HRs of all-cause mortality in the lowest SES group were 4.00 (95% CI, 3.25-4.93) in patients aged 20-39 years, 2.71 (95% CI, 2.59-2.84) in those aged 40-59 years, and 1.58 (95% CI, 1.54-1.62) in those aged 60-79 years. A similar association was observed in cause-specific mortality. Conclusion: Low SES increased the risks of all-cause mortality and mortality from cardiovascular disease, diabetes, and cancer in patients with diabetes. This association is more prominent in younger patients than in older patients. Disclosure J.Kim: None. N.Kim: None. S.Kim: None.

The role of geographic disparities in outcomes after orthopaedic trauma surgery

IntroductionHealthcare disparities linked to patient rurality and socioeconomic status are known to exist, but few studies have examined the effect of urban versus rural status on outcomes after orthopedic trauma surgery. The aim of this study was to examine the correlation between patient rurality, socioeconomic status, and outcomes after orthopedic trauma. Materials and methodsThis is a retrospective cohort study of patients diagnosed with a hip or long bone fracture between January 2016 and December 2017. Data were collected from the Nationwide Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population. Patients were stratified into 3 groups: isolated hip fracture, isolated long bone fracture, and polytrauma. Bivariate analysis was completed using chi-squared tests for categorical variables and t-tests for continuous variables. Multivariable analysis was completed using population-weighted logistic regression models, based on a conceptual model derived selection of covariates. ResultsWe included 235,393 patients diagnosed with a hip or extremity fracture. These were weighted to represent 1,176,965 patients nationally. In the hip fracture group, rural patient status was associated with higher odds of mortality (OR 1.32, P < 0.001) but not complications (OR 0.95, P = 0.082). In the extremity fracture and polytrauma groups, rural patient status was not associated with significantly higher odds of mortality or complications. In the urban polytrauma group, zip code with below-median income was associated with increased odds of mortality (OR 1.23, P = 0.002) but not complications. In the rural polytrauma group, zip code with below-median income was not associated with significantly increased odds of mortality or complications. In the hip fracture and extremity fracture groups, below-median income was not associated with significantly higher odds of mortality. ConclusionWe found that rural patients with hip fracture have higher mortality compared to urban patients and that socioeconomic disparities in mortality after a polytrauma exist in urban settings. These results speak to the ongoing need to develop objective measures of disparity-sensitive healthcare and optimize trauma systems to better serve low-income patients and patients in rural areas.

Socioeconomic Disparities Do Not Explain the U.S. International Disadvantage in Mortality.

The articles examines the contribution of internal socioeconomic disparities in mortality to the U.S. international disadvantage in life expectancy at birth. Using individual death records from the U.S. national vital statistics system for years 1982-2019 and data for other countries from the Human Mortality Database, we compare age-specific death rates and life expectancy between counties classified into 10 socioeconomic categories and 20 high-income countries. We also calculate the number of years of life lost in each socioeconomic decile in relation to the comparison set. There is a clear and increasing socioeconomic gradient of mortality in the United States, but the growing divergence in internal mortality trends does not explain the rising gap between the country and its peers. In 2019, even American women in the most socioeconomically advantaged decile lived shorter lives, while only 10% of men in the most affluent decile fared better than their peers. The long-standing U.S. disadvantage in young adult mortality has been growing and the country's previous advantage in mortality at ages 75 years and older has virtually disappeared for all but for Americans in the most affluent counties. The similar age pattern of differences in mortality rates between each socioeconomic deciles and the comparison group suggests that the underlying factors might be the same. The role of external causes (including drug overdoses) for middle-aged adults and a slowing down in progress to control cardiovascular diseases at older ages at the national level are consistent with this pattern.

Why we should monitor disparities in old-age mortality with the modal age at death.

Indicators based a fixed “old” age threshold have been widely used for assessing socioeconomic disparities in mortality at older ages. Interpretation of long-term trends and determinants of these indicators is challenging because mortality above a fixed age that in the past would have reflected old age deaths is today mixing premature and old-age mortality. We propose the modal (i.e., most frequent) age at death, M, an indicator increasingly recognized in aging research, but which has been infrequently used for monitoring mortality disparities at older ages. We use mortality and population exposure data by occupational class over the 1971-2017 period from Finnish register data. The modal age and life expectancy indicators are estimated from mortality rates smoothed with penalized B-splines. Over the 1971-2017 period, occupational class disparities in life expectancy at 65 and 75 widened while disparities in M remained relatively stable. The proportion of the group surviving to the modal age was constant across time and occupational class. In contrast, the proportion surviving to age 65 and 75 has roughly doubled since 1971 and showed strong occupational class differences. Increasing socioeconomic disparities in mortality based on fixed old age thresholds may be a feature of changing selection dynamics in a context of overall declining mortality. Unlike life expectancy at a selected fixed old age, M compares individuals with similar survival chances over time and across occupational classes. This property makes trends and differentials in M easier to interpret in countries where old-age survival has improved significantly.

Abstract 14405: Impact of Educational Attainment on All-Cause and Cardiovascular Mortality: Findings From a National Study of US Adults

Introduction: Education is an important determinant of cardiovascular disease (CVD). However, the extent to which educational attainment impacts the risk of all-cause and cardiovascular (CV) mortality on a population level is relatively understudied. Methods: We used data from 2006-2014 National Death Index-linked National Health Interview Survey for adults ≥ 18 years. We generated age-adjusted mortality rates (AAMR) by levels of education (&lt; High School (HS), HS/General Education Development (GED), Some College, and &gt; College) in adults with and without CVD. Cox proportional hazards models were used to examine the association between educational attainment and all-cause and CV mortality. Results: Final sample comprised of 256,991 participants (mean age=46.3), representing ~230 million adults annually, of which 8% had ASCVD. Overall, 14.8% of participants had &lt;HS education and 27.3%, 19.9% and 38.0% had HS/GED, Some College, and &gt; College education, respectively. During a median follow-up of 4.5 (IQR: 2.5-6.8) years (1179 million person-years), all-cause and CV AAMRs were approximately 1.5 and 2 fold higher, respectively, for &lt;HS vs. &gt;College education in the CVD population and 2 fold higher in the non-CVD population ( Figure 1 ). In fully adjusted models, &lt; HS (reference= &gt;College) was associated with 20% increased risk of all-cause (HR 1.20, 95% CI: 1.07-1.35) and 40% increased risk of CV mortality (HR 1.41, 95% CI: 1.10-1.81) in the CVD population, compared to 40-45% increased risk of mortality in the non-CVD population (all-cause mortality HR 1.39, 95% CI: 1.29-1.49; CV mortality HR 1.45, 95% CI: 1.20-1.75). Similar trends were seen by race/ethnicity (data not shown). Conclusions: Lower education is an independent predictor of all-cause and CV mortality in both CVD and non-CVD populations. Efforts for integration of educational attainment into existing CV risk prediction algorithms are needed to mitigate observed socioeconomic disparities in mortality.

Does urban greenspace reduce racial and socioeconomic disparities in mortality in Philadelphia, PA?

BACKGROUND AND AIM: A small body of research suggests greenspace may reduce socioeconomic health inequalities. Little is known about whether this effect extends to racial health disparities. We investigated if higher amounts of tree canopy cover or perceived park access were linked to smaller disparities in all-cause and cardiovascular (CVD) mortality rates by neighborhood SES or race composition in Philadelphia, PA. METHODS: We linked census-tract level mortality count data (years 2008-2015) with % living in poverty and % non-Hispanic Black data from the American Community Survey; LiDAR derived % tree canopy measures, and survey derived estimates of % of residents reporting perceived park access. We used age-adjusted negative binomial models, including the natural logarithm of age-specific population counts as an offset, to estimate associations between % non-Hispanic Black and % poverty (categorized in quartiles) with all-cause and CVD mortality. We quantified heterogeneity of associations across quartile-based categories of % tree canopy and perceived park access, by inclusion of interaction terms. RESULTS:Rates of mortality were higher in tracts with higher % residents living in poverty, and higher % non-Hispanic Black residents (e.g., Relative Rate [RR] of CVD mortality, highest vs. lowest quartile of % non-Hispanic Black: 1.57, 95% CI: 1.44 – 1.70). Disparities in mortality rates across categories of % living in poverty were smaller in areas with more greenspace (RR for high vs. low % poverty census tracts: 1.03 [95% CI: 0.77,1.36] among tracts with high % residents reporting access to parks; 1.76, [95% CI: 1.33, 2.33] among tracts with low % residents reporting access to parks). By contrast, disparities in mortality across non-Hispanic Black composition categories persisted, regardless of tree canopy cover or park access. CONCLUSIONS:Our preliminary results suggest that greenspace may reduce socioeconomic, but not racial health disparities. Further research is needed to clarify the reasons underlying these differences. KEYWORDS: Green space, Environmental disparities, Socio-economic factors (non-chemical stressors), Mortality, Environmental justice

The gendered widowhood effect and social mortality gap

With few exceptions, greater disparities in mortality risk by socio-economic status (SES) have been found among men than among women. Most research has also shown that the higher mortality risk after widowhood (the widowhood effect) is greater for men. However, a different picture appears when examining these associations jointly. Based on Swedish register data, this study shows that widowhood weakens, or even reverses, the sex differences in socio-economic disparities in mortality. The overall findings also indicate that higher SES elevates the widowhood effect for men but diminishes it for women, and that the widowhood effect is greater for women than men in the lowest SES categories. These results imply that men with higher SES are more vulnerable after widowhood, perhaps because of their previous relatively privileged situation. The disadvantage of widows in lower SES categories may reflect exposure to financial strains after spousal loss and inequalities in the healthcare system.

Social Inequality and the Future of U.S. Life Expectancy.

Despite decades of progress, the future of life expectancy in the United States is uncertain due to widening socioeconomic disparities in mortality, continued disparities in mortality across racial/ethnic groups, and an increase in extrinsic causes of death. These trends prompt us to scrutinize life expectancy in a high-income but enormously unequal society like the United States, where social factors determine who is most able to maximize their biological lifespan. After reviewing evidence for biodemographic perspectives on life expectancy, the uneven diffusion of health-enhancing innovations throughout the population, and the changing nature of threats to population health, we argue that sociology is optimally positioned to lead discourse on the future of life expectancy. Given recent trends, sociologists should emphasize the importance of the social determinants of life expectancy, redirecting research focus away from extending extreme longevity and towards research on social inequality with the goal of improving population health for all.

Socioeconomic disparities in U.S. mortality: The role of smoking and alcohol/drug abuse.

Prior studies have identified smoking as a key driver of socioeconomic disparities in U.S. mortality, but the growing drug epidemic leads us to question whether drug abuse is exacerbating those disparities, particularly for mortality from external causes. We use data from a national survey of midlife Americans to evaluate socioeconomic disparities in all-cause and cause-specific mortality over an 18-year period (1995–2013). Then, we use marginal structural modeling to quantify the indirect effects of smoking and alcohol/drug abuse in mediating those disparities. Our results demonstrate that alcohol/drug abuse makes little contribution to socioeconomic disparities in all-cause mortality, probably because the prevalence of substance abuse is low and socioeconomic differences in abuse are small, especially at older ages when most Americans die. Smoking prevalence is much higher than drug/alcohol abuse and socioeconomic differentials in smoking are large and have widened among younger cohorts. Not surprisingly, smoking accounts for the majority (62%) of the socioeconomic disparity in mortality from smoking-related diseases, but smoking also makes a substantial contribution to cardiovascular (38%) and all-cause mortality (34%). Based on the observed cohort patterns of smoking, we predict that smoking will further widen SES disparities in all-cause mortality until at least 2045 for men and even later for women. Although we cannot yet determine the mortality consequences of recent widening of the socioeconomic disparities in drug abuse, social inequalities in mortality are likely to grow even wider over the coming decades as the legacy of smoking and the recent drug epidemic take their toll.

Premature Mortality in Canada

Introduction: Premature mortality (deaths before age 75) is a well-established metric of population health and health system performance. In Canada, underlying differences between provinces/territories present a need for stratified mortality trends.&#x0D; Methods: Using data from the Canadian Vital Statistics Database, a descriptive analysis of sex-specific adult premature deaths over 1992-2015 was conducted by province, census divisions (CD), socioeconomic status (SES), age, and underlying cause of death. Premature mortality rates were calculated as the number of deaths per 100,000 individuals aged 18 to 74, per 8-year era. SES was measured using the income quintile of the neighbourhood of residence. Absolute and relative inequalities were respectively summarized using slope and relative indices of inequality, produced via unadjusted linear regression of the mortality rate on income rank.&#x0D; Results: Premature mortality in Canada declined by 21% for males and 13% for females between 1992-1999 and 2008-2015. The greatest reductions were in Central Canada, while Newfoundland saw notable increases. CD-level improvements appeared mostly in the southern half of Canada. As of 2008-2015, Newfoundland, Nova Scotia, and Nunavut had the highest mortality rates. Low area-level income was associated with higher mortality. SES inequalities grew over time. Newfoundland’s between-quintile differences rose from 1292 to 2389 deaths per 100k males, or 1.33 to 2.12-fold, and 586 to 1586 per 100k females, or 1.24 to 1.74-fold. In 2008-2015, mortality rates of the bottom quintile in Manitoba and Saskatchewan were more than 2.5 times those of the top. Mortality increased with age, and varied regionally. Low mortality in Central Canada and BC, and high mortality in the Territories were consistent across eras and sexes. Cause of death distributions shifted with age and sex, with more external deaths in younger males.&#x0D; Conclusion: Improvements were seen in adult premature mortality rates over time, but were unequal across geographies. Evidence exists for growing socioeconomic disparities in mortality.

Do area-level factors reduce individual-level socioeconomic mortality disparities associated with particulate matter?

Do area-level factors reduce individual-level socioeconomic mortality disparities associated with particulate matter?

Socioeconomic disparities in life expectancy gains among retired German men, 1997–2016

BackgroundAlthough estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the...

Socioeconomic determinants of mortality for very old men in Austria

Although socioeconomic differences in the mortality of middle-aged persons is well-researched, little is known about socioeconomic inequalities in mortality in the very old population. Surveys and population census follow-up studies in this age group are associated with reliability and validity problems. The aim of the study was to investigate, by linking statistical information from register data, to what extent differences in mortality exist among very old Austrian men by socioeconomic variables (e.g. education and income) and if these can be explained by differences in health status. The data records on men aged 80-99years counted in the Austrian register-based population census from 2011 were augmented by information from tax and social security data and merged with deaths in a5-year follow-up period. Relative mortality risks were estimated by Cox regression. The health status was operationalized by the standardized level of care. Even in very old men significant differences in mortality exist depending on the socioeconomic status. Asystematic effect was found for education and apoverty effect for income. When controlling not just for age but also for the standardized level of care, no socioeconomic disparities in mortality were observed. The higher mortality risk for less educated and low income very old men is thus a result of a poorer health status. At ages over 80 years the health status is the essential influencing factor on mortality. Measures to reduce socioeconomic disparities in mortality must therefore focus on earlier phases in life, in order to reduce the extent of care dependency among socially disadvantaged groups.

Area-based socioeconomic disparities in mortality due to unintentional injury and youth suicide in British Columbia, 2009-2013.

The association between health outcomes and socioeconomic status (SES) has been widely documented, and mortality due to unintentional injuries continues to rank among the leading causes of death among British Columbians. This paper quantified the SES-related disparities in the mortality burden of three British Columbia's provincial injury prevention priority areas: falls among seniors, transport injury, and youth suicide. Mortality data (2009 to 2013) from Vital Statistics and dissemination area or local health area level socioeconomic data from CensusPlus 2011 were linked to examine age-standardized mortality rates (ASMRs) and disparities in ASMRs of unintentional injuries and subtypes including falls among seniors (aged 65+) and transport-related injuries as well as the intentional injury type of youth suicide (aged 15 to 24). Disparities by sex and geography were examined, and relative and absolute disparities were calculated between the least and most privileged areas based on income, education, employment, material deprivation, and social deprivation quintiles. Our study highlighted significant sex differences in the mortality burden of falls among seniors, transport injury, and youth suicide with males experiencing significantly higher mortality rates. Notable geographic variations in overall unintentional injury ASMR were also observed across the province. In general, people living in areas with lower income and higher levels of material deprivation had increasingly higher mortality rates compared to their counterparts living in more privileged areas. The significant differences in unintentional and intentional injury-related mortality outcomes between the sexes and by SES present opportunities for targeted prevention strategies that address the disparities.

Role of allostatic load and health behaviours in explaining socioeconomic disparities in mortality: a structural equation modelling approach

BackgroundThe relationship between socioeconomic status and mortality has been well established; however, the extent to which biological factors mediate this relationship is less clear, and empirical evidence from non-Western settings...